Grand Multiparas and Home Birth

Is a mother who has already had five or more full-term pregnancies at higher risk? Can she still plan a home birth?

My family, all six born at home, with newborn Tommy

The concern in the past has been mainly that grand multiparae (mothers who have given birth five times before) were at higher risk of postpartum haemorrhage and some other complications, because the uterus might lose its elasticity and therefore might not contract down well after the birth. It has been hard to give women an accurate estimate of the risks they face, because most of the research into grand multiparas comes from the developing world - where women may not have access to rapid, good-quality emergency care. It's not hard to see that a woman expecting her 10th baby in Somalia, who may have to walk for a day in hard labour to reach a clinic, faces higher risks than a woman in the UK who is attended by a qualified midwife and has access to drugs to treat postpartum haemorrhage, and can transfer to hospital by ambulance if there are any concerns.

The latest UK-based research suggests that in fact a woman who is healthy and who does not have a history of such complications is not significantly more likely to be at risk in labour simply because she is a grand multipara. Below you will find research abstracts, and a review from a professor of midwifery, which suggest that a woman's previous obstetric history and personal health are more relevant than the fact that she has a large family. The older studies which led to these worries may have been misleading because control groups were not matched for age or for pre-existing health problems such as diabetes or high blood pressure.

Note that early pregnancy losses do not count towards your 'parity', ie towards the number of times you are considered to have given birth. Some studies count only pregnancies which lasted until 24 weeks, others 28 weeks. A few have earlier cut-off points, but first-trimester miscarriages, and early second trimester, are never considered part of your total.

[Aside: your 'gravidity' is the number of times you have been pregnant. Your 'parity' is the number of times you have given birth. So a woman on her fourth pregnancy, who has had 2 miscarriages and one live baby, is a 'G4P1' - Gravida 4, Para 1]

UK Research on Grand Multiparity

In March 2002 the British Journal of Obstetrics and Gynaecology published a new study of grand multiparae in the UK. The authors concluded that:

"In a developed country with satisfactory health care conditions, grandmultiparity should not be considered dangerous, and risk assessment should be based on past and present history and not simply on the basis of parity"

What is a labour like for a grand multipara?

Anecdotally, it seems that when women have given birth several times before, they often have a long prelabour period where contractions may build up, but labour does not become established. It may be hard for them to be sure when they are going into labour, because labour appears to start, then contractions stop. This pattern may continue over several days; with my own fourth baby, fifth baby and sixth baby (ninth pregnancy) it continued over about a week.

This can be frustrating and tiring, especially when you have several older children to look after. However, these on-off contractions are usually doing some work; they are helping to move the baby into a good position and to efface and perhaps dilate your cervix. It is common for the established labour to be short, or easy (but not necessarily both!) after a long prelabour.

A woman planning a hospital birth, who was having contractions every five minutes, and then found that her contractions stopped, might be put on a syntocinon drip to bring on powerful contractions. This augmentation of labour is generally more painful than natural labour, and it can lead to other interventions. That's fine if you are finding it extremely stressful dealing with the uncertainty of when your labour will finally get going, but if you are happy to wait then be aware than you do not have to consent to have your labour sped up in this way.

If you are planning a homebirth, you have more flexibility - you can accept the stop-start labour, make the most of any rest you can get, and stay close to home, or you can transfer to hospital to have your labour induced. You might also have the opportunity to have your waters broken at home, to see if this brings on established labour. Breaking the waters is known to increase the risk of foetal distress and of infection, and it can make labour much more intense, very suddenly, which some women find hard to deal with. Research suggests that on average it only shortens labour by a small amount, but some midwives feel that there are cases where it makes a real difference.

As long as you and your baby are healthy, and your baby's heart rate is not showing any signs of distress, remember that there is nothing "wrong" with a labour which progresses as a series of rests and jumps. You don't have to transfer to hospital just because your labour is not progressing according to the same timetable that applies to a woman having her first baby. Some women feel it is a very efficient way to labour - like so many other parts of your life, you fit this task into family life in manageable chunks, not all at once!

The birth stories below help to illustrate the diversity of labour patterns that a woman with a large family might experience.

Birth Stories

These mothers have had home births for fifth or subsequent babies:

<Naomi W had her 7th baby at home, very quickly, with just two of her other children there for company. Her midwife and husband arrived shortly afterwards to find a very competent mother with a healthy baby. In case this all sounds a little too easy, Naomi had endured the traditional lot of mothers of large families - seemingly endless 'Is it? Isn't it?' prelabour and weeks of irregular contractions which didn't appear to be doing anything, when her baby was in the OP position.

Athena, my own fifth baby, was born after a dream of a labour - much easier and faster than all the others, and with minimal blood loss. My sixth baby, Tommy, was also born at home after a straightforward, short established labour, but long, long prelabour - again, with little blood loss. I haven't written his birth story up yet.

Sun had her fifth, sixth, seventh, eighth, ninth and tenth babies at home.

Victoria's fifth baby was born at home after a very tough labour - posterior, with both hands by her face.

Lesley Page's Case Study

I strongly recommend reading Chapter 1 of 'The New Midwifery - Science and Sensitivity in Practice' by Lesley Page (Churchill Livingstone, 2000). Lesley Page is a highly respected professor of midwifery. If you cannot obtain the book, ask your midwives; they may well have it in their unit's library.

Page reviews eleven studies on grand multiparity and adverse outcome, and four on grand multiparity and postpartum haemorrhage risk. Most of the studies were conducted in less-developed countries. Where conducted in developed countries, on further examination it was found that many participants were actually immigrants from deprived backgrounds. Even so, only four studies of the eleven found an association between grand multiparity and adverse outcome. Of the studies on postpartum haemorrhage, Page found that 'None of the studies reviewed demonstrated a **direct association** between grand multiparity and a higher probability of postpartum haemorrhage' (p35).

Page notes that it is important to assess whether the study's findings are valid, important enough to make a difference, and then whether it can be applied to the individual woman who she is caring for. Considering the case of Jane, a woman expecting her seventh baby in the UK, who was in good health and who wanted a home birth, Page concluded:

"I could find no sound evidence to support the belief that grand multiparity on its own is a predictor of severe adverse outcome, and the four studies of post-partum haemorrhage indicated no association between grand multiparity and postpartum haemorrhage. None of the risk factors for postpartum haemorrhage identified by these studies (weight of baby, ethnicity, previous PPH and pre-eclampsia, for example) applied to Jane. Given her clinical history... I decided that Jane did not have a higher probability of pospartum haemorrhage than other less parous women in the population" (P35)

This study is not mentioned in Page's review as it was published two years after her book - but it appears to be a good quality study and is highly relevant to women considering home birth in developed countries.

OBJECTIVE: To compare the incidence of antenatal and intrapartum complications and neonatal outcomes among women who had previously delivered five or more times (grandmultiparous) with that of age-matched control women who had previously delivered two or three times (multiparous).
DESIGN: A matched cohort study.
SETTING: An inner city university maternity hospital in the United Kingdom.
SAMPLE: Three hundred and ninety-seven grandmultiparous women were compared with three hundred and ninety-seven age-matched multiparous women.
METHODS: Data on the subjects were obtained from a computerised maternity information system (SMMIS). Characteristics and complications occurring in the two groups were compared. Data validation was performed with a 10% randomised sample of the casenotes in both groups. Nineteen relevant data fields were abstracted and compared with the matched SMMIS record.

CONCLUSION: This study suggests that in a developed country with satisfactory health care conditions, grandmultiparity should not be considered dangerous,and risk assessment should be based on past and present history and not simply on the basis of parity.
PMID: 11950178 [PubMed - indexed for MEDLINE]

My own brief review of studies

I have searched Medline and found abstracts of the following studies. All relevant studies thrown up by the search are included; I have not excluded any because, eg, I did not like their findings!!

The impression that I have come away with is that grand multigravidas should be watched closely for diabetes and hypertension/pre-eclampsia, but if these complications are not present then there do not appear to be any significant extra risks for a woman expecting her 5th baby, in a developed country.

Some of these studies were not included in Lesley Page's review - either because they were published after she conducted the review, or perhaps because the studies did not fulfil her inclusion criteria. Of the studies I list below, Page mentions [4] Goldman et all (1995), [5] Kaplan et al (1995), [6] Hughes and Morrison (1994), [11] Seidman et al (1988), [12] Eidelman et al (1988), [17] King et al (1991)., [18] Tai and Urquhart (1991)

Definitions

Definitions do not seem to be consistent; some of the studies below define women as:

PARITY VERSUS GRAVITY
Also confusing because 'parity' strictly means how many births you have already had, whereas 'gravity' means how many pregnancies... so a nullipara has no previous births but is a primigravida, in her first pregnancy. A 'primip' is short for primipara, but is often used to refer to someone having their first birth.... although strictly it sounds as if it should only apply after the birth! 'Nullipara' is actually the correct corollary for a woman who has not given birth before. Not sure if all papers below use this consistently.

PARITY VERSUS AGE
Many studies are hard to compare - eg studies of high parity women tend to look at less developed countries where this is more common. Since many women of high parity are 35+ years old as well, it is also hard to unravel the different effects of age and parity. For example,
"Diabetes, hypertension, malpresentations, multiple births, large-for-gestational-age deliveries and perinatal deaths were found to be significantly more common in 1,542 multiparae who had seven or more deliveries. The association between parity and age partially accounted for this observation. " [9:Israel]

"No increase in obstetric complications or neonatal morbidity and mortality was found among the offspring of the grand multiparous mothers. Having taken socioeconomic status into account, we conclude that grand multiparity does not carry an increased risk of perinatal morbidity or mortality. " [11: Israel]

Comparing multiparas with Grand multiparas: "There were minimal differences in major antenatal, peripartum and neonatal outcome events, with the exception of a high rate of gestational and pre-existing diabetes." [6: United Arab Emirates]

The second to fifth pregnancy is "ideal"; beyond that, "transverse lie, primary uterine inertia, fetal heart rate abnormalities, failure to progress and postpartum hemorrhage were encountered significantly more often than in the other groups." [8: Saudi Arabia]

Placental abruption may be more likely in women who have 5 or more previous births [13:Jordan]

Grand multiparity was *not* associated with increased risk of postpartum haemorrhage in several studies [12:Israel, 14:Nigeria, 15:Zimbabwe], but did appear to be in others [8,10: Saudi Arabia, 2:USA]

Some risks are increased by grand multiparity, whilst others are reduced, according to this study:"The incidence of postpartum hemorrhage, preeclampsia, placenta previa, macrosomia, postdate pregnancy, and low Apgar scores was significantly higher in grand multiparas than in multiparas, whereas the proportion of induction, forceps delivery, and total labor complications was significantly lower than in the multiparous group" [2: USA]

Birth complications, including severe haemorrhage, significantly more likely in huge multiparas(10th baby or more) than in grand multiparas according to one study.. [16, Israel]

But another found that, for huge multiparas on baby 10+, "The study group showed significantly lower rates of low birth weight infants and instrumental delivery. No significant difference was seen in the incidence of cesarean section, pathologic fetal presentation, maternal hypertension, gestational diabetes, hemorrhage, or perinatal morbidity or mortality." [5:Israel]

This appears to refer to a high-risk population; 15% had no antenatal care.
"Transverse presentation, preterm delivery, meconium-stained amniotic fluid, and placental lysis or uterine exploration were more frequent in the (grand)multiparous group ... Newborn infants in the (grand)multiparous group were severely asphyxiated at birth more frequently than those in the control group" [7, Yugoslavia]

Good outcomes need not be dependent on socioeconomic status; "An excellent maternal and perinatal outcome is reported in a group of grand multipara of low socioeconomic status" [17: Hong Kong]

"Apart from a significant increase in the incidence of anaemia, women of parity 5 and 6 had a similar obstetric performance and perinatal outcome to that of the control group. We conclude that grandmultiparity per se is not an obstetric risk factor until after the seventh delivery" [18: Malaysia]

"In a largely Hispanic population grand multiparous patients do not have an increased incidence of intrapartum complications." [19: USA Toohey et al, 1995]

Medline Abstracts in Full

These abstracts are copied direct from Medline. If you would like to look them up on Medline for yourself, it is easy to find them simply by copying the title into the 'search' box.

[1]
Grandmultiparity. Is it a perinatal risk?
AUTHORS: Samueloff A; Schimmel MS; Eidelman AI
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel.
SOURCE: Clin Perinatol 1998 Sep;25(3):529-38
CITATION IDS: PMID: 9779332 UI: 98452368
ABSTRACT: Increased parity is more common in lower-socioeconomic groups. Additionally, GMPs tend to be older. It is for these reasons that there is a tendency for an increased incidence of antenatal complications, such as hypertension and diabetes, among GMP mothers. It appears that the previous conflicting reports on the effect of high parity on perinatal outcome can be related to differences in the socioeconomic conditions of the parturient population under examination. Previous evidence of the unfavorable influence on perinatal outcome of high parity might have been biased by patient selection, because high parity is often inversely linked to social class. Our recent studies of the Israeli maternal population plus comparable reports from other countries allow us to conclude that GMP is not always a great cause for concern in an economically stable and healthy population that has access to high-quality medical care. As such, the term dangerous multipara should be removed from the medical literature and the focus of concern should shift to the organization and the delivery of quality medical services.

[2] Perinatal outcome in grand and great-grand multiparity: effects of parity on obstetric risk factors.
AUTHORS: Babinszki A; Kerenyi T; Torok O; Grazi V; Lapinski RH; Berkowitz RL
AUTHOR AFFILIATION: Division of Maternal-Fetal Medicine, Department of Obstetrics, Sinai School of Medicine, New York, NY, USA.
SOURCE: Am J Obstet Gynecol 1999 Sep;181(3):669-74
CITATION IDS: PMID: 10486482 UI: 99417457
ABSTRACT: OBJECTIVE: We sought to compare obstetric and neonatal complications among great-grand multiparous, grand multiparous, and multiparous women. STUDY DESIGN: One hundred thirty-three great-grand multiparas, 314 grand multiparas, and 2195 multiparas who were delivered of their infants between 1988 and 1998 were selected for the study. To facilitate comparison, the patients were all >35 years old and had similar socioeconomic characteristics. RESULTS: The incidence of malpresentation at the time of delivery, maternal obesity, anemia, preterm delivery, and meconium-stained amniotic fluid increased with higher parity, whereas the rate of excessive weight gain and cesarean delivery decreased. Compared with grand multiparas, great-grand multiparas had significantly elevated risks for abnormal amounts of amniotic fluid, abruptio placentae, neonatal tachypnea, and malformations but lower rates of placenta previa (P <.05). The incidence of postpartum hemorrhage, preeclampsia, placenta previa, macrosomia, postdate pregnancy, and low Apgar scores was significantly higher in grand multiparas than in multiparas, whereas the proportion of induction, forceps delivery, and total labor complications was significantly lower than in the multiparous group (P <.05). Similar frequency of maternal diabetes, infection, uterine wall scar rupture, variations in fetal heart rate, fetal death, and neonatal mortality was found in the 3 groups.
CONCLUSION: Both high-parity groups have their own risk factors, but the rate of some complications decreases with higher parity. In addition, perinatal mortality remains low in these patients, and therefore, under satisfactory socioeconomic and health care conditions, high parity should not be considered dangerous.

[3] The clinical outcome in pregnancies of grand grand multiparous women.
AUTHORS: Juntunen K; Kirkinen P; Kauppila A
AUTHOR AFFILIATION: The Family Federation, Infertility Clinic of Oulu, Finland.
SOURCE: Acta Obstet Gynecol Scand 1997 Sep;76(8):755-9
CITATION IDS: PMID: 9348253 UI: 98006476
ABSTRACT: OBJECTIVE: To longitudinally evaluate maternal and neonatal complications with relation to birth order, with specific emphasis on grand grand multiparity (at least 10th para). METHODS: The maternal and neonatal outcome of 1200 pregnancies/deliveries in 96 grand grand multiparas was longitudinally investigated in 4 stages of the mothers' life: the primiparas, the multiparas (2nd-5th paras), the grand multiparas (6th-9th paras) and the grand grand multiparas stage.
RESULTS: The frequency of hypertension, diabetes, placental complications, operative interventions at delivery, macrosomic infants, chromosomal abbreviations and fetal/neonatal anomalies increased with increasing birth order, being at a maximum in grand grand multiparas. The preterm delivery and perinatal mortality rate did not differ between the 3 groups of multiparas. Perinatal outcome was good in each group. CONCLUSIONS: Grand grand multiparity carries the risk of hypertensive and diabetic complications, which, in turn, often lead to induced or operative deliveries and placental complications. However, grand grand multiparity is not a major problem in societies with a good maternal health care system.

[4]The grand multipara.
AUTHORS: Goldman GA; Kaplan B; Neri A; Hecht-Resnick R; Harel L; Ovadia J
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Beilinson Medical Center, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Israel.
SOURCE: Eur J Obstet Gynecol Reprod Biol 1995 Aug;61(2):105-9
CITATION IDS: PMID: 7556829 UI: 96058149
ABSTRACT: Grandmultiparity (GMP) has long been considered an obstetric complication for both mother and fetus, although recent studies indicate that, with proper perinatal care, women with high-parity rates are no longer at high risk. The current study examines the outcome of delivery in 1700 women in their fifth or more delivery, as compared with two control groups: 622 primiparas and 735 multiparas (two to three previous deliveries). Excellent prenatal care was available free of charge to all parturients. Our objectives were to evaluate the management of GMP in contemporary obstetrics and to assess whether grand multiparas are still high-risk patients. The age of the grandmultiparas was significantly higher compared with with the control groups, which may explain the higher incidence among them of antenatal medical disorders, such as diabetes mellitus and hypertensive disease. No significant differences were found among the three groups for preterm or post-term births, small-for-gestational-age infants, polyhydramnios, oligohydramnios, perinatal death, fetal distress, multiple births, placenta previa, abruptio placentae or cord prolapse. Macrosomia was markedly higher in the grandmultiparas and multiparas than in nulliparas. Thus, our results indicate that good perinatal care can ensure better results in grandmultiparas, and that grandmultiparity no longer needs to be considered a high-risk obstetric category in our population.

[5] Great grand multiparity--beyond the 10th delivery.
AUTHORS: Kaplan B; Harel L; Neri A; Rabinerson D; Goldman GA; Chayen B
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Beilinson Medical Center, Petah-Tikva, Israel.
SOURCE: Int J Gynaecol Obstet 1995 Jul;50(1):17-9
CITATION IDS: PMID: 7556854 UI: 96035532
ABSTRACT: OBJECTIVE: To investigate the perinatal outcome and obstetric complications of women delivering for the 10th time or more. METHODS: Four hundred twenty women of great grand multiparity were analyzed in a modern health care setting and compared with our general population of obstetric patients, with regard to past history, maternal age, gestational age, mode of delivery, fetal outcome and intercurrent medical/obstetric problems. RESULTS: The study group showed significantly lower rates of low birth weight infants and instrumental delivery. No significant difference was seen in the incidence of cesarean section, pathologic fetal presentation, maternal hypertension, gestational diabetes, hemorrhage, or perinatal morbidity or mortality. There was a slightly higher incidence of twin births compared with the general population.
CONCLUSION: It is probable that women capable of reaching their 10th delivery are basically healthy. If offered adequate perinatal care, they are not a high-risk group during subsequent deliveries.

[6] Grandmultiparity--not to be feared? An analysis of grandmultiparous women receiving modern antenatal care.
AUTHORS: Hughes PF; Morrison J
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, Faculty of Medicine and Health Sciences, UAE University, Al Ain.
SOURCE: Int J Gynaecol Obstet 1994 Mar;44(3):211-7
CITATION IDS: PMID: 7909758 UI: 94229313
ABSTRACT: OBJECTIVE: To document the reproductive performance of grandmultiparous women receiving modern antenatal care. METHODS: A cross-sectional study of 2784 multiparous (882 grandmultiparous) mothers delivered in a base hospital obstetric unit staffed by western-trained midwives and consultant obstetrical staff. RESULTS: There were minimal differences in major antenatal, peripartum and neonatal outcome events, with the exception of a high rate of gestational and pre-existing diabetes.
CONCLUSIONS: This data supports the opinion that grandmultiparity per se is not necessarily a major risk factor for either mother or fetus. Similarly, the mature grandmultigravida in this population was not at significantly increased risk of the alleged associations of increased parity and advancing maternal age, with the exception of diabetes. Together with the combined prevalence of maternal anemia this requires further investigation and probable intervention, particularly in the light of recent speculation concerning the fetal and infant origins of adult disease.

[7]
NOTE THAT THIS STUDY USES 'PLURIPARAS' FOR WOMEN ON 2ND-4TH PREGNANCIES, AND 'MULTIPARAS' FOR 5TH ONWARDS. APPARENTLY FROM A RELATIVELY HIGH-RISK POPULATION - Yugoslavia??

[Pregnancy, labor and the neonate in pluriparas and multiparas]
VERNACULAR TITLE: Trudnoca, porodaj i novorodence pluripare i multipare.
AUTHORS: Mikulandra F; Perisa M; Merlak I; Kimer M; Sikic D; Jerkovic J
AUTHOR AFFILIATION: Sluzba za zastitu zdravlja zena Medicinskog centra, Sibeniku.
SOURCE: Jugosl Ginekol Perinatol 1990 May-Aug;30(3-4):83-6
CITATION IDS: PMID: 2273908 UI: 91109392
ABSTRACT: From 1971 to 1988, out of 22001 deliveries (multiple pregnancies excluded) 212 (0.96%) occurred in multiparas with five or more deliveries. The control group included 7340 pluriparas (two to four deliveries) from the same period. In 82.1% cases the multiparas were para 5 and 6, and 63 (29.7%) were less than 34 years of age. 15.9% had no antenatal visit; for the most part they were housewives and rural pregnant women. Transverse presentation, preterm delivery, meconium-stained amniotic fluid, and placental lysis or uterine exploration were more frequent in the multiparous group (P less than 0.001), whereas cervical cerclage and episiotomy were more frequent in the control group (P less than 0.05). Newborn infants in the multiparous group were severely asphyxiated at birth more frequently than those in the control group (P less than 0.05). There were no differences as regards late fetal and early neonatal deaths between the two study groups. The overall perinatal death rate in the multiparas and pluriparas was 2.83% and 1.81%, respectively (P less than 0.05). There was no case of uterine rupture or maternal death in the multiparous and pluriparous group.

[8] PARA 2-5 IS 'IDEAL' ACCORDING TO THIS!

The grand multipara in modern obstetrics.
AUTHORS: Evaldson GR
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Huddinge University Hospital, Karolinska Institutet, Stockholm, Sweden.
SOURCE: Gynecol Obstet Invest 1990;30(4):217-23
CITATION IDS: PMID: 2289702 UI: 91146952
ABSTRACT: From April 1985 to March 1986, 1,252 women were admitted for delivery at the Al Hada Armed Forces Hospital, Taif, Saudi Arabia. Of these, 224 (17.9%) were grand multiparas (GM) defined as mothers of parity greater than or equal to 6. History, labor and delivery as well as postpartum and neonatal courses were recorded using computerized records for later statistical calculations. The obstetric and perinatal outcome was calculated comparing the GMs to para-1 mothers and para-2-5 patients (P2-5), respectively. The latter group being empirically considered as the 'ideal' patient group. On comparing the GM group to that of P2-5, significantly higher frequencies of intercurrent diseases, especially diabetes mellitus and gestational diabetes, were found. Among GMs, transverse lie, primary uterine inertia, fetal heart rate abnormalities, failure to progress and postpartum hemorrhage were encountered significantly more often than in the other groups. The incidence of placenta previa was likewise significantly increased among the GMs as was the number of cesarean sections, particularly those of the primary emergency type. There was no maternal mortality. The perinatal morbidity was significantly higher in the GM group. However, no significant difference in perinatal mortality was found between the groups. It is concluded that with few exceptions the GM can be safely delivered by means of modern obstetric management.

[9] Grand multiparity--a nationwide survey.
AUTHORS: Samueloff A; Mor-Yosef S; Seidman DS; Rabinowitz R; Simon A; Schenker JG
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Hadassah University Hospital, Jerusalem, Israel.
SOURCE: Isr J Med Sci 1989 Nov;25(11):625-9
CITATION IDS: PMID: 2687205 UI: 90077798
ABSTRACT: Grand multiparity has been considered to be an obstetric hazard to both the mother and the fetus. In order to evaluate this statement we analyzed the information of a nationwide survey. The delivery records of all women (22,814) attending 30 obstetric wards in Israel between November 1983 and January 1984 were analyzed and the medical and obstetric complications associated with grand multiparity were investigated. Diabetes, hypertension, malpresentations, multiple births, large-for-gestational-age deliveries and perinatal deaths were found to be significantly more common in 1,542 multiparae who had seven or more deliveries. The association between parity and age partially accounted for this observation.

[10] The problem of grandmultiparity in current obstetric practice.
AUTHORS: Mwambingu FT; Al Meshari AA; Akiel A
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, King Abdul Aziz University Hospital, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
SOURCE: Int J Gynaecol Obstet 1988 Jun;26(3):355-9
CITATION IDS: PMID: 2900162 UI: 88297001
ABSTRACT: A retrospective analysis of 646 Arab grandmultiparas who booked for hospital confinement between 1983 and 1985 was carried out. The results were compared with that of non-grandmultiparas during the same period. In the grandmultiparas, the incidences of gestational diabetes, hypertension rheumatic heart disease, antepartum, postpartum hemorrhage and macrosomic infants were increased. However, contrary to some previous reports the incidences of anemia, cesarean sections, induced labor, dysmaturity and perinatal deaths were decreased. This is thought to be due to the provision of modern specialist perinatal care and improved socioeconomic standards.

[11] Grand multiparity: an obstetric or neonatal risk factor?
AUTHORS: Seidman DS; Armon Y; Roll D; Stevenson DK; Gale R
AUTHOR AFFILIATION: Department of Neonatology, Bikur Cholim Hospital, Jerusalem, Israel.
SOURCE: Am J Obstet Gynecol 1988 May;158(5):1034-9
CITATION IDS: PMID: 3369480 UI: 88220410
ABSTRACT: Grand multiparity has been considered to be a factor in maternal and neonatal morbidity. In addition, families with seven or more children have been associated with low socioeconomic status. To minimize the confounding effect of the socioeconomic status, the outcome of grand multiparity has been investigated in a mostly homogeneous, ultraorthodox Jewish community in Jerusalem, Israel. A total of 5916 deliveries in one community hospital (Bikur Cholim) were studied, of which 893 (13%) occurred in mothers who had given birth to seven or more infants. There was a significant decrease in the incidence of small for gestational age infants among the grand multiparous women (3.6% as opposed to 5.8% in the control population). This difference was independent of maternal age. Moreover, grand multiparous women gave birth to significantly more large for gestational age infants. No increase in obstetric complications or neonatal morbidity and mortality was found among the offspring of the grand multiparous mothers. Having taken socioeconomic status into account, we conclude that grand multiparity does not carry an increased risk of perinatal morbidity or mortality.

[12] The grandmultipara: is she still a risk?
AUTHORS: Eidelman AI; Kamar R; Schimmel MS; Bar-On E
AUTHOR AFFILIATION: Department of Pediatrics, Albert Einstein College of Medicine, Yeshiva University, Bronx, New York.
SOURCE: Am J Obstet Gynecol 1988 Feb;158(2):389-92
CITATION IDS: PMID: 3341414 UI: 88131188
ABSTRACT: Grandmultiparity is reported to increase both maternal and perinatal mortality and morbidity. Unique religious and demographic factors in Jerusalem allowed us to analyze a population wherein parity could be dissociated from socioeconomic status. A total of 7785 mothers was studied, 889 (11.5%) of whom were grandmultiparas. Comparison of grandmultiparous mothers with all others revealed no increase in the incidence of hypertension, diabetes, uterine atonia, antenatal or postnatal hemorrhage, cesarean sections, stillbirth rate, or congenital malformations. The grandmultipara had significantly lower neonatal mortality and low birth weight rates and a significantly higher incidence of multiple births and trisomy 21 (p less than 0.01). These results strongly suggest that grandmultiparity in and of itself in a healthy, economically stable population afforded modern medical care is not a major risk factor and that previous reports primarily reflected social class factors and not parity per se.

[13] Abruptio placentae: risk factors and perinatal outcome.
AUTHORS: Abu-Heija A; al-Chalabi H; el-Iloubani N
AUTHOR AFFILIATION: Department of Obstetrics and Gynecology, Jordan University of Science and Technology, Irbid, Jordan.
SOURCE: J Obstet Gynaecol Res 1998 Apr;24(2):141-4
CITATION IDS: PMID: 9631603 UI: 98295081
ABSTRACT: OBJECTIVE: It is a case control study, conducted in order to determine the risk factors, and to find out the perinatal outcome of abruptio placentae in women delivered at the Princess Badeea Teaching Hospital in North Jordan. METHODS: We reviewed all cases of placental abruption delivered between 15th April 1994 till 26 November 1995 and to compare that with pregnancies and deliveries not complicated by abruptio placentae. RESULTS: During the study period there were 108 cases of abruptio placentae and 108 cases of the control group. The total number of women delivered were 18,256, so the incidence of abruptio placentae was 5.9 per 1000 births. When compared to the control group, abruptio placentae occurred more in parous women (para > or = 5) (p < 0.0005), more preterm deliveries (p < 0.0001) with more birth weight < 2,500 g (p < 0.0001). Preeclampsia and pregnancy induced hypertension, intrauterine growth retardation, caesarean delivery, and intrauterine fetal death occurred more in patients with abruptio placentae. CONCLUSION: High parity, preeclampsia and hypertension are significant etiological determinants of abruptio placentae.

HIGH PARITY APPEARS **NOT** TO INCREASE PPH RISK

[14] Risk factors for primary postpartum haemorrhage. A case control study.
AUTHORS: Selo-Ojeme DO; Okonofua FE
AUTHOR AFFILIATION: Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria.
SOURCE: Arch Gynecol Obstet 1997;259(4):179-87
CITATION IDS: PMID: 9271837 UI: 97417779
ABSTRACT: The objective of the study was to determine which background factors predispose women to primary postpartum haemorrhage (PPH) at the Obafemi Awolowo University Hospital. The study consisted of 101 women who developed PPH after a normal vaginal delivery and 107 women with normal unassisted vaginal delivery without PPH Both cases and controls were investigated for sociodemographic risk factors, medical and obstetric histories, antenatal events and labour and delivery outcomes. Data were abstracted from the medical and delivery records and risks were estimated by multivariate logistic regression. The results of the univariate analysis revealed a number of potential risk factors for PPH but after adjustment by logistic regression three factors remained significant. These were prolonged second and third stages of labour and non-use of oxytocics after vaginal delivery. Previously hypothesised risk factors for PPH such as grand multiparity, primigravidity and previous episodes of PPH were not significantly associated with PPH. We conclude that primary PPH in this population is mostly associated with prolonged second and third stages of labour and non use of oxytocics. Efforts to reduce the incidence of PPH should not only be directed at proper management of labour but also training and retraining of primary health care workers and alternative health care providers in the early referral of patients with prolonged labour.

GRAND MULTIPARITY APPEARS **NOT** TO INCREASE PPH RISK

[15] Postpartum haemorrhage in Zimbabwe: a risk factor analysis [see comments]
AUTHORS: Tsu VD
SOURCE: Br J Obstet Gynaecol 1993 Apr;100(4):327-33
CITATION IDS: PMID: 8494833 UI: 93264355
COMMENT: Comment in: Br J Obstet Gynaecol 1993 Dec;100(12):1152
ABSTRACT: OBJECTIVES: To identify risk factors associated with postpartum haemorrhage (PPH) in order to improve the effectiveness of antenatal screening. DESIGN: A population-based case control study. SETTING: Harare, Zimbabwe. SUBJECTS: Two groups of women, one group consisting of those with postpartum haemorrhage after a normal vaginal delivery and the other of women with normal unassisted vaginal delivery without PPH. METHOD: Data abstracted from the medical records; relative risks were estimated by multivariate logistic regression. RESULTS: Low parity, advanced maternal age, and antenatal hospitalisation were among the strongest risk factors, with more modest associations for history of poor maternal or perinatal outcomes and borderline anaemia at the time of booking. No association with grand multiparity was found. CONCLUSIONS: These findings confirm the importance of previously recognised factors such as low parity, poor obstetric history, anaemia, and prolonged labour, but call into question the significance of grand multiparity. Previously undocumented factors such as maternal age greater than 35 years and occiput posterior head position emerged as predictors worthy of further investigation.

[17]
Grand multiparity: a reappraisal of the risks
King PA, Duthie SJ, Ma HK.
Department of Obstetrics and Gynaecology, University of Hong Kong.
Int J Gynaecol Obstet 1991 Sep;36(1):13-6
An excellent maternal and perinatal outcome is reported in a group of grand multipara of low socioeconomic status. These observations on a group of patients who are traditionally considered to be high risk show that in a healthy population with access to modern medical care and hospital delivery, a favorable outcome can be achieved despite a low socioeconomic or refugee status.
PMID: 1683295 [PubMed - indexed for MEDLINE]

[18]
Grandmultiparity in Malaysian women.
Tai C, Urquhart R.
Department of Obstetrics and Gynaecology, University Hospital, Kuala Lumpur, Malaysia.
Asia Oceania J Obstet Gynaecol 1991 Dec;17(4):327-34
Grandmultiparity is an ill defined term, but it is generally believed that increasing parity after the fifth delivery increases the risks of child bearing for both the mother and fetus. Four hundred seventy-seven women aged less than 35 years of parity 5 and above who delivered during one year period at the University Hospital, Kuala Lumpur were studied. There were 406 women of parity 5 and 6 and 71 women of parity 7 and above. The 2 groups as a whole comprised 7.5% of the obstetric population for that year. Obstetric performance in the 2 groups of grandmultipara was compared with 1,135 women, aged 25 to 34 years, having their second baby during the same period. Women of parity 7 and above were significantly more likely to be from lower socioeconomic groups, and suffer from anaemia, hypertension and pre-eclampsia. They were also significantly at risk of preterm delivery and delivering infants weighing less than 2.5 kg. In addition, the perinatal mortality rate was significantly greater in the highly parous group (Para greater than 7) than in women of parity 5 and 6 or the control group.
Apart from a significant increase in the incidence of anaemia, women of parity 5 and 6 had a similar obstetric performance and perinatal outcome to that of the control group. We conclude that grandmultiparity per se is not an obstetric risk factor until after the seventh delivery. These findings have implications for those who plan the provision of obstetric services for the community.
PMID: 1801678 [PubMed - indexed for MEDLINE]

[19] The "dangerous multipara": fact or fiction?
Toohey JS, Keegan KA Jr, Morgan MA, Francis J, Task S, deVeciana M.
Department of Obstetrics and Gynecology, University of California
Am J Obstet Gynecol 1995 Feb;172(2 Pt 1):683-6
OBJECTIVE: Our purpose was to compare the intrapartum complication incidence among grand multiparous women with that of age-matched control multiparous women. STUDY DESIGN: A total of 382 grand multiparous women (para > or = 5) were compared with 382 age-matched control subjects (para 2 to 4), all delivering between July 1989 and September 1991. Intrapartum complications classically associated with grand multiparity (abruptio placentae, dysfunctional labor, fetal malpresentation, postpartum hemorrhage, and shoulder dystocia) were compared. RESULT: Both groups had comparable antepartum complications and gestational ages at delivery. The overall intrapartum complication incidence for grand multiparous women was 33% (127/382 patients), not significantly different from that of the control multiparous women, 27% (103/382). Grand multiparity was associated with an increased incidence of macrosomia (16% vs 11%) and a decreased incidence of operative delivery (14% vs 21%). Macrosomia increased the incidence of intrapartum complications from 31% to 46% (p < 0.03) in the grand multiparous patients, and a trend was observed in the multiparous patients, from 26% to 37%. However, when properly controlled, this was noted to be a confounding variable and was not related to parity. CONCLUSIONS: In a largely Hispanic population grand multiparous patients do not have an increased incidence of intrapartum complications.
PMID: 7856706 [PubMed - indexed for MEDLINE]